I am Forbes' Opinion Editor. I am a Senior Fellow at the Manhattan Institute for Policy Research, and the author of How Medicaid Fails the Poor (Encounter, 2013). In 2012, I served as a health care policy advisor to Mitt Romney. To contact me, click here. To receive a weekly e-mail digest of articles from The Apothecary, sign up here, or you can subscribe to The Apothecary’s RSS feed or my Twitter feed. In addition to my Forbes blog, I write on health care, fiscal matters, finance, and other policy issues for National Review. My work has also appeared in National Affairs, USA Today, The Atlantic, and other publications. I've appeared on television, including on MSNBC, CNBC, HBO, Fox News, and Fox Business. For an archive of my writing prior to February 2011, please visit avikroy.net. Professionally, I'm the founder of Roy Healthcare Research, an investment and policy research firm. In this role, I serve as a paid advisor to health care investors and industry stakeholders. Previously, I worked as an analyst and portfolio manager at J.P. Morgan, Bain Capital, and other firms.

Aaron Carroll will heave a great sigh when he sees me write about this, but the Center for Studying Health System Change—the group behind the Medicaid physician access data I highlighted on Monday—has just put out a new study on the topic. Peter Cunningham, author of the study, captures the gist of it in this sentence: “Growth in Medicaid enrollment [especially in the South and Mountain West] will greatly outpace growth in the number of primary care physicians willing to treat new Medicaid patients.”

The reason why the South and Mountain West will be disproportionately affected is because those states currently have relatively smaller Medicaid programs that will be more dramatically expanded by PPACA, combined with a lower ratio of primary care physicians per capita. “Things are not going to be pretty in those states,” said Alwyn Cassil of CSHSC in an interview with Kaiser Health News.

In response to my concerns about how Medicaid’s absurdly low reimbursement rates have led physicians to stop participating in the program, some have pointed out that PPACA raises Medicaid reimbursement rates to (declining) Medicare rates in 2013 and 2014. However, in order to maintain the fiction that PPACA is “deficit neutral,” the law reverts back to Medicaid’s older, lower rates in 2015. Cunningham points out that, as a result, the temporary rate increase is likely to have no effect on physician access:

A limitation of this analysis is that the simulated rate increases assumed a permanent increase in Medicaid reimbursement relative to Medicare, while the rate increases specified in the law are limited to 2013 and 2014. The temporary nature of the rate increase may limit the incentive for more physicians to accept Medicaid patients, in which case the increase in Medicaid PCP supply will be less than shown in this analysis. While the federal government and/or states have the option of extending these increases beyond 2014, budgetary pressures and uncertainty about what shortages will develop when reform is implemented are likely to preclude decisions on extensions.

“If you thought the [temporarily] increased Medicaid reimbursement was going to get a lot more doctors to jump in and be willing to take on new Medicaid patients, it’s not going to work that way,” notes Cassil.

Furthermore, it’s important to remember that Medicaid’s problems are not limited to access to primary care. Indeed, a major reason why Medicaid beneficiaries fared so poorly in the UVa surgical outcomes study is that Medicaid patients have poor access to specialists—especially the high-volume surgical specialists who are proven to deliver superior clinical outcomes when compared to generalists.

My critics say that I’m “cynical” because I say that Medicaid’s reimbursement rates are too low, and yet oppose spending more money that we don’t have. This is a false dichotomy. There are a lot of things we can do to make Medicaid more cost-efficient: starting with converting the program into block grants for the states, and letting states focus on fully funding care for the truly needy.

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In this matter you are incorrect, the number of physicians in the US is higher now than it has ever been, both in absolute numbers and in proportion to the total population. In 1980 there were 1.9 MDs per thousand and in 2006 it was 2.7. In 1987 there were just over 3 million medical workers of all sorts employed in hospitals while in 2007 it was nearly 4.5 million. An even more interesting statistic is that in 1987 there 0.08 Full Time Equivalent (FTE) medical employees per adjusted admission* while in 2007 it was 0.07. There are more medical schools and medical students than at any time in history. There are similar results for RNs and various specializations. There is a shortage of GP physicians and MDs in rural and poor urban areas but on the whole, there is no shortage of supply of medical service providers.

*An aggregate measure of workload reflecting the number of inpatient admissions, plus an estimate of the volume of outpatient services, expressed in units equivalent to an inpatient admission in terms of level of effort.

Here a useful link to the Bureau of Health Professionals

http://bhpr.hrsa.gov/healthworkforce/reports/factbook.htm

Looking at Table 1 it can be seen that number of physicians per 100,000 population has steadily increased between 1970 and 2000.

http://bhpr.hrsa.gov/healthworkforce/reports/factbook02/FB101.htm

In fact, in 1970 there 156 MD /HT while in 1975 it was 174, 1980 it was 196, 1985 it was 221, 1990 it was 237, 1995 it was 255, and in 2000, it was 280. Similar trends can be seen in the various specializations and allied professions.

So there is no shortage of physicians, if anything there is an oversupply. Perhaps this is why medical costs keep going up, there are more and more doctors supported by fewer and fewer patients.

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The number of doctors isn’t a useful number on its own. You have to run that number alongside increases in health care utilization. If the supply of apples increases by 5x, but the demand for apples increases by 10x, the price of apples will go up.